Dr. JK asks:
I extracted tooth #6 [maxillary right canine] which had a vertical fracture on the buccal and sinus tract. I traced the sinus tract with a gutta-percha cone and a periapical radiograph. The tooth was removed and moderate granulation tissue was removed. There was a dehiscence and Bio-Oss with BioGuide membrane were used to close the gap. Primary closure was obtained.
A bonded provisional was used and 6 months later a 5x16mm tapered implant was used with 40Ncm fixation. More Bio-Oss was placed on the buccal to reinforce the hard and soft tissue. An immediate temporary abutment and crown (light interproximal contacts and completely out of occlusion)were utilized.
Five months have gone by. Soft tissue looks normal and with adequate volume. However, about 4mm coronal to the gingival margin there is a sinus tract. It was traced and radiographically it stops on the buccal of the implant. The implant is not mobile and integration from the radiograph is WNL. Probing is normal and the pt is asymptomatic. How would you approach this issue? My first thought is full thickness flap and surgical exploration/ possible degranulation and subsequent bone grafting. Would appreciate any thoughts.
Its worth a try. Make sure the defect is only on the buccal, then attempt to add bone etc.. If it extends into the palate, then its hopeless and remove the implant and repair the defect. Good luck!
I agree with Mike Lang. If you have a palatal wall then you have a fighting chance. My only addition is: try an approach that does not raise a conventional flap. Make your incisions apical to the gingival margin (as in a apicoectomy.) If the level of attached tissue permits, make a horizontal incision in the keratinized tissue and two small verticals, making sure this soft tissue window will be wide enough to appropriately debride the site and have a membrane extend beyond the bony defect. I am only suggesting this method because it is in the anterior region. Good Luck.
try this:
semi lunar incision buccally over the sinus expose and remove granulation tissue and disinfect with betadine/chlorohexidine in the area copious amounts followed by gentymycin powder then bioss/membrane with autogenous bone chips in the area close and hope 4 the best – if palatal wall has gone trephine out the implant /graft and replace – good luck
4 perio:
why would you wanna do your cut into the keratinized tissue , its gonna be more traumatic and difficult to close vs. if you go 2 mm apical to th ekeratinized tissue i.e, non keratinized mucosa. you will have more giving tissue to suture at.
what i would do, i would first try curetting the sinus and deepithilaize it if a fistula is formed. do good irrigation with NS, give the pt blutsyring to keep irrigating the site at home with NS, see him in 1 week. i am optimist that this can help regranulating the defect.
i disagree about the “corn flakes” technique by avika denta …. sorry buddy … rationalize what you are suggesting… in both your surgicaL and medical intevention.
to 4 perio – I think u misunderstood what I was trying to say similar to your previous to last comment the incison would be in non-keratinised mucosa as a semi lunar type – obviously with relieving incisions if required – but both of us have neither seen the patient or are aware of the situation here so perhaps you could be more open minded about generalised comments on a case that u have not seen xrays or photos of the problem – also can u explain the “corn flakes” comment – In an ideal world then explain why microbiology – should be sent a swab to check what species of bacteria is present and appropriate antimicrobial therapy directly applied as an adjunct to any surgical intervention – and interestly have you tried the technique you described – and can you provide any long term studies to back up the technique you describe that would be interesting
Actually, if you make the incisions in the keratinized tissue, and it’s beveled, you should have less scarring and it will be easier to suture. Placing your incisions only in mucosa may lead to significant scarring and the sutures may pull through the weaker tissue
Sorry guys, maybe I wasn’t completely clear why it is advantageous to make your incisions in keratinized mucosa. I am glad JW understood. Also, AVIK- I didn’t advocate this Corn Flakes technique. Back to the original point- Dr JK, how is it going with site, what technique did you use and is it working well?
I have had this problem once before and it healed after irrigation with corsodyl. Hard to believe but true! I also have another case which I have done multiple resurgeries on but will not heal. It is fully integrated ISQ 86 on the ostell with palatal bone etc… Have even tried to make it fail with electrocautery without any luck… Time for the trephine I spose.
Dear Colleagues,
The basics of surgery suggest that one should debride and exise the whole of sinus tract and not remove a small amount of granulation. I find it sane enough to wait for three weeks and re expose the site and fill it up with any graft if you want. Sorry if I might sound radicle but it helps. We are not in a mad rush to place implants but to osseointegrate them for long term.
Ambrish Maniar
#6 labial sinus tract- If the abutment is loose or if there is some cement subgingival this can happen.